Medicine: Rheum Flashcards
What are the key parts to a rheum hx?
PC - joint pain, stiffness, swelling
SHx - functionality, job, driver, smoking, drug compliance
SRV - skin, eyes, renal, constitutional, fatigue
What does the timing of the stiffness indicate?
Early morning, within ~half an hr, inflammatory
Worsens throughout the day infers more degenerative
What is the DAS28?
Disease Activity Score - 28 Joints
Number swollen and tender, inflam marker, global assessment
How does the DAS28 score translate to disease activity?
> 5.1 Active
<3.2 Low
<2.6 Remission
Which is arguably the most important aspect of rheum exams?
Looking
Talk through the hand exam
LOOK
Elbows, hands, skin, nails, palms, finger pulps
FEEL
Pulses, muscle bulk, snuffbox, tendon thickening, sensation, temp, squeeze MCPs then individually each MCP PIP DIP and wrists, sensation
MOVE
Active prayer and reverse, passive wrist flexion/extension, extend fingers, splay, push hands down, thumb, fists
FUNCTION
Power grip, pincer grip, pick up small object/do up button/hold pen, Tinel’s, Phalen’s, Froment’s, Finkelstein’s
What are you looking for in the elbows?
Psoriatic plaques, rheumatoid nodules, olecranon bursa, gout tophi
Where else should you look if you’re suspicious of gout?
The pinna of the ear
What are your looking for in the hands?
Hands: swelling, loss of alignment, muscle wasting, scars, symmetry
Skin/nails: pitting, ridging, nail fold vasculitis
Palms/finger pulps: palmar erythema and scars from carpal tunnel release
Boutonniere deformity @ PIP and DIP
Flexion @ PIP
Extension @ DIP
Swan neck deformity @ PIP and DIP
Extension @ PIP
Flexion @ DIP
What do nail signs suggest?
Clubbing - cardio, resp, gastro
Pitting - psoriasis
Koilinychia - iron def
Leukonychia - liver disease
Splinters - vasculitis
How do you test sensation in the hands?
Median - over thenar eminence
Ulnar - over hypothenar eminence
Radial - thumb and index webspace
Plus can do C678 dermatomes
Describe Phalen’s test
If you suspect carpal tunnel, perform reverse prayer for 60s or squeeze wrist and force into flexion for 30s, pos if any tingling/numbness
SEs of colchicine
Nausea, vomiting, diarrhoea
Which three qs do you always ask at the start of the GALS screen?
Pain and stiffness, dressing, stairs
- Do you have any pain or stiffness in your muscles, joints or back?
- Can you dress yourself completely w/o any difficulty?
- Can you walk up and down the stairs w/o any difficulty?
GALS: What are you looking for in the gait?
Smoothness, symmetry, ability to turn quickly
NB: heal to toe and tip toe walking is more neuro looking for cerebellum problems
GALS: What are you looking for during inspection?
-From Behind-
Trapezius and gluteal muscle bulk size and symmetry
Spinal alignment
Level iliac crests
Popliteal obv swelling
Hindfoot abnormalities
GALS: What are you looking for in the spine?
-From Side-
Cervical lordosis
Thoracic kyphosis
Lumbar lordosis
Schober’s test
Knee flexion/hyperextension
What does Schober’s test assess?
Lumbar flexion by placing two fingers on adjacent vertebrae and asking the pt to touch their toes and come back up again
GALS: What are you looking for in the arms?
-From Front-
Muscle bulk and symmetry
Elbow extension in anatomical position
Cervical spine lateral flexion each side
Open jaw wide and move side to side
Elbow flexion w hands behind head
Crude hand exam inc fists, thumb to each finger, power grip and squeeze across MCPs
What is TMJ pain often a/w?
RA and inflam joint disease
What else does putting hands behind head w elbow back test?
Humeral movement and functionality
GALS: What are you looking for in the legs?
-Lying Down-
Passive knee flexion, hip flexion, hip internal rotation
Patellar tap looking for a large effusion
Sweep/bulge test looking for smaller effusions
Crude foot exam inc callus formation and squeeze across MTPs